Colorado Department of Health Care Policy and Financing Dental Benefits Collaborative Recommendations: Outpatient/Office Pediatric Dentistry and Orthodontics Benefits Friday, October 25, 2013 1 Colorado Department of Healthcare Policy and Financing Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources
Meeting Ground Rules • Tough on issues, not people • One person speaking at a time • Be concise/ share the air • Listen for understanding, not disagreement • Speak up here, not outside • In the room: Phones on silent/ vibrate • On the phone: Please mute your line • Please introduce yourself & state your affiliation when asking a question or making a comment 2 Colorado Department of Health Care Policy and Financing
Contact Information Kimberley D. Smith Benefits Collaborative Coordinator Health Programs Services & Supports Division 1570 Grant Street, Denver, CO 80203 Phone: (303) 866-3977 Email: Kimberley.Smith@state.co.us 3 Colorado Department of Health Care Policy and Financing
Benefits Collaborative Overview 4 Colorado Department of Health Care Policy and Financing
Purpose of Benefits Collaborative Ensure Benefit Coverage Standards: • Are guided by recent clinical research and evidence based best practices • Are cost effective and establish reasonable limits upon services • Promote the health and functioning of Medicaid clients 5 Colorado Department of Health Care Policy and Financing
Participant Role Per SB13-242, the Department retains ultimate decision making authority over the Medicaid dental benefit design. However, the collaborative exists to assist the Department in its design of cost effective, evidence based standards by contributing in the following ways: • Share diverse perspectives to expand understanding ahead of decision making • Share new information/research • Ask questions and provide informed insight in response to analysis offered and suggestions made 6 Colorado Department of Health Care Policy and Financing
Department Role The Department will: • Work with participants to ensure that input is consistently understood and considered • Wherever possible, work to ensure that input is reflected in alternatives developed • Provide feedback on how input influenced decisions made and explanation when input cannot be incorporated/adopted 7 Colorado Department of Health Care Policy and Financing
Introducing: Dr. Randi Tillman and Dr. Scott Navarro 8 Colorado Department of Health Care Policy and Financing
Frame for Discussion at Today’s Meeting Topics closed to discussion Topics open for today: discussion today: – Access (provider types, – Coverage geographic distribution and recruitment) – Coding – Payment (fee schedules) – Professional Policies – Delivery model & network ( Outpatient/Office options Pediatric Dentistry and – Operational considerations & Orthodontics Benefits ) processes – Annual Maximum for Adults – Dept. intent to change – Current claims issues/ the payment customer service questions mechanism for – The HLD Colorado orthodontic services modification score sheet 9 Colorado Department of Health Care Policy and Financing
Colorado Department of Health Care Policy and Financing Dental Benefits Collaborative Recommendations: Outpatient/Office Pediatric Dentistry and Orthodontics Friday, October 25, 2013 10
Objectives and Assumptions Objective: To develop recommendations for pediatric dental and orthodontic benefits for Colorado Medicaid recipients that is cost effective and provides orthodontic services for medically necessary orthodontic treatment. For purposes of these recommendations the following assumptions will apply: All benefit coverage will be at 100%. There will be no copays or coinsurance. Benefits will apply until a recipient turns age 21. 11
Evidence Based Dentistry Is the Integration of: Evidence-based dentistry is an approach to oral Best Evidence health care that requires the judicious integration of systematic assessment of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences. Clinical Judgment Patient Values/Circumstances …to improve health. 12 Source: Richard Niederman
Dental Benefit Design Recommendations: Outpatient/Office Pediatric Dentistry 13
Background: Children and Dental Disease According to the Pew Foundation: Tooth decay is the most common childhood disease; 5 times more common than asthma. Children who do not receive routine dental care are more likely to miss school and to use expensive emergency room facilities for the relief of pain. Results from National Health and Nutrition Examination Study Decay of primary teeth is on the increase in younger children. 42% have had decay in their primary teeth Children belonging to highly vulnerable groups (such as minorities and those with low family incomes) have more decay. Almost a quarter of children in this age group have untreated decay. 14
Pediatric Dentistry Discussion Goals for Today Address those pediatric procedures conducted in an office or outpatient setting. Procedures related to inpatient settings will be discussed at the Benefits Collaborative meeting on December 6, 2013. Focus on those areas in which benefits for children, defined as under age 21, differ from those already discussed for the adult population. 15
Unique Pediatric Benefits Code Description Frequency Coverage Comments 0145 Oral Evaluation for Patient Once every 6 100% May be reported with under Age 3 and Counseling months prophy, x-rays and with Primary Caregiver fluoride application. (includes anticipatory guidance) 2930 Prefabricated stainless steel Once per tooth per 100% Stainless steel crowns crown / primary tooth lifetime can be expected to last until exfoliation. 2931 Prefabricated stainless steel May be replaced 100% Up to age 18. crown/permanent tooth every 36 months 2933 Prefabricated stainless steel Once per tooth per 100% Stainless steel crowns crown with resin window lifetime can be expected to last until exfoliation. 3220 Pulpotomy Once per tooth per 100% Not the first stage of root lifetime; for primary canal treatment. teeth only 1510, 1515 Fixed space maintainers for Once per lifetime per 100% Under age 10. lost primary molars arch 16
Cleanings, Fluoride and Minor Restorative Code Description Frequency Coverage Comment 1120 Child Cleaning (prophylaxis) 2 per 12 months 100% Unless indication of high risk; then up to 4 times per year. 1206 Fluoride varnish 2 per 12 months 100% Unless indication of high risk; then up to 4 times per year. 1208 Topical fluoride 2 per 12 months 100% Unless indication of high risk; then up to 4 times per year. 2140 One surface amalgam 1 per 36 months 100% 2150 Two surface amalgam 1 per 36 months 100% 2160 Three surface amalgam 1 per 36 months 100% 2161 Four surface amalgam 1 per 36 months 100% 2330 One surface anterior 1 per 36 months 100% composite 2331 Two surface anterior 1 per 36 months 100% composite 2332 Three surface anterior 1 per 36 months 100% composite 2335 Four surface anterior 1 per 36 months 100% composite 17
Minor Restorative (continued) Code Description Frequency Coverage Comment 2390 Resin based 1 time per 36 100% composite crown, months anterior 2391 One surface 1 time per 36 100% Allowed for first pre-molars composite posterior months only; otherwise payment level equals amalgam; dentist may not balance bill. 2392 Two surface 1 time per 36 100% Allowed for first pre-molars composite posterior months only; otherwise payment level equals amalgam; dentist may not balance bill. 2393 Three surface 1 time per 36 100% Allowed for first pre-molars composite posterior months only; otherwise payment level equals amalgam; dentist may not balance bill. 2394 Four surface 1 time per 36 100% Allowed for first pre-molars composite posterior months only; otherwise payment level equals amalgam; dentist may not balance bill. 18
Policies Specific to Pediatric Dental Care Permanent crowns are not approved for children under the age of 16 (codes 2710-2794). Restorations for primary teeth that are close to exfoliation will not be approved. Endodontic therapy for permanent teeth only; once per lifetime. 19
Dental Benefit Design Recommendations: Orthodontics 20
Orthodontics Significant increases have occurred in both the number of orthodontic cases and the cost per case in recent years in the State of Colorado for Medicaid clients. The increases in orthodontic expenditures for the Medicaid program appear to be significantly out of proportion to the increase in Medicaid enrollment. Cautionary tales from other states (e.g., Texas) need to be considered. 21
Orthodontic Payment Policy Today, the entire orthodontic treatment fee is paid at the initiation of treatment. To our knowledge, few (if any) other states pay this way. Moving forward, orthodontic treatment payments will no longer be paid in full upfront. 22
The Challenge There is a need for a standard and transparent methodology for evaluating medical necessity. Researched other state policies; including CA, NC and other states as prototypes. 23
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